Hemoglobinopathies

Definition

Hemoglobinopathies are genetic (inherited) disorders of hemoglobin, the oxygen-carrying protein of the red blood cells.

Description

The hemoglobin molecule is composed of four separate polypeptide chains of amino acids, two alpha chains and two beta chains, as well as four iron-bearing heme groups that bind oxygen. The alpha chains are coded for by two similar genes on chromosome 16; the beta chains by a single gene on chromosome 11. Mutations and deletions in these genes cause one of the many hemoglobinopathies.

In general, hemoglobinopathies are divided into those in which the gene abnormality results in a qualitative change in the hemoglobin molecule and those in which the change is quantitative. Sickle cell anemia (sickle cell disease ) is the prime example of the former, and the group of disorders known as the thalassemias constitute the latter. It has been estimated that one third of a million people worldwide are seriously affected by one of these genetic disorders.

Causes and symptoms

Sickle cell anemia (SSA), an autosomal recessive disorder more common in the Black population, is caused by a single mutation in the gene that codes for the beta polypeptide. Approximately 1/400 to 1/600 African-Americans are born with the disorder, and, one in ten is a carrier of one copy of the mutation. In certain parts of the African continent, the prevalence of the disease reaches one in fifty individuals.

The sickle cell mutation results in the substitution of the amino acid valine for glutamic acid in the sixth position of the beta polypeptide. In turn, this alters the conformation of the hemoglobin molecule and causes the red blood cells to assume a characteristic sickle shape under certain conditions. These sickle-shaped cells, no longer able to pass smoothly through small capillaries, can block the flow of blood. This obstruction results in symptoms including growth retardation, severe pain crises, tissue and organ damage, splenomegaly, and strokes. Individuals with SSA are anemic and prone to infections, particularly pneumonia, a significant cause of death in this group. Some or all of these symptoms are found in individuals who have the sickle mutation in both copies of their beta-globin gene. Persons with one abnormal gene and one normal gene are said to be carriers of the sickle cell trait. Carriers are unaffected because of the remaining normal copy of the gene.

The thalassemias are a diverse group of disorders characterized by the fact that the causative mutations result in a decrease in the amount of normal hemoglobin. Thalassemias are common in Mediterranean populations as well as in Africa, India, the Mideast, and Southeast Asia. The two main types of thalassemias are alpha-thalassemia due to mutations in the alpha polypeptide and beta-thalassemia resulting from beta chain mutations.

Since individuals possess a total of four genes for the alpha polypeptide (two genes on each of their two chromosomes 16), disease severity depends on how many of the four genes are abnormal. A defect in one or two of the genes has no clinical effect. Abnormalities of three results in a mild to moderately severe anemia (hemoglobin H disease) and splenomegaly. Loss of function of all four genes usually causes such severe oxygen deprivation that the affected fetus does not survive. A massive accumulation of fluid in the fetus (hydrops fetalis) results in stillbirth or neonatal death.

Beta thalassemias can range from mild and clinically insignificant (beta thalassemia minor) to severe and life-threatening (beta thalassemia major, also known as Cooley's anemia), depending on the exact nature of the gene mutation and whether one or both copies of the beta gene are affected. While the milder forms may only cause slight anemia, the more severe types result in growth retardation, skeletal changes, splenomegaly, vulnerability to infections, and death as early as the first decade of life.

Diagnosis

Many countries, including the United States, have made concerted efforts to screen for sickle cell anemia at birth because of the potential for beginning early treatment and counseling parents about their carrier status. Diagnosis is traditionally made by blood tests including hemoglobin electrophoresis. Similar tests are used to determine whether an individual is a sickle cell or thalassemia carrier. In certain populations with a high prevalence of one of the mutations, carrier testing is common. If both members of a couple are carriers of one of these conditions, it is possible through prenatal genetic testing to determine if the fetus will be affected, although the severity of the disease cannot always be predicted.

Treatment

Treatment of SSA has improved greatly in recent years with a resulting increase in life expectancy. The use of prophylactic (preventative) antibiotic therapy has been particularly successful. Other treatments include fluid therapy to prevent dehydration, oxygen supplementation, pain relievers, blood transfusions, and several different types of medications. Recent interest has focused on bone marrow transplantation, which has been successful in selected patients.

Since the clinically important thalassemias are characterized by severe anemia, the traditional treatment has been blood transfusion, but the multiple transfusions needed to sustain life lead to an iron overload throughout the tissues of the body and eventual destruction of the heart and other organs. For this reason, transfusion therapy must also include infusions of medications such as deferoxamine (desferroxamine) to rid the body of excess iron. Phlebotomy is another technique that has been used with some success to lower the concentration of iron in the patient's blood. As with sickle cell anemia, bone marrow therapy has been successful in some cases.

Until very recently, patients being treated with bone marrow transplants had to find a sibling or other closely related donor in order to avoid rejection of the transplant. Advances in the preparation of the transplanted cells, however, have made the use of bone marrow from unrelated donors (URD) an option for patients with hemoglobinopathies. As of 2003, the National Marrow Donor Program reports that about 40% of bone marrow transplants involve a patient in the United States receiving marrow from an international donor or an international patient receiving marrow from a donor in the United States.

Emphasis is also being placed on developing drugs that treat sickle cell anemia directly. The most promising of these drugs in the late 1990s is hydroxyurea, a drug that was originally designed for anticancer treatment. Hydroxyurea has been shown to reduce the frequency of painful crises and acute chest syndrome in adults, and to lessen the need for blood transfusions. Hydroxyurea seems to work by inducing a higher production of fetal hemoglobin. The major side effects of the drug include decreased production of platelets, red blood cells, and certain white blood cells. The effects of long-term hydroxyurea treatment are unknown; however, a nine-year follow-up study of 299 adults with frequent painful crises reported in 2003 that taking hydroxyurea was associated with a 40% reduction in mortality.

Another promising development for the treatment of hemoglobinopathies is gene therapy, which has interested researchers since the early 1990s. In late 2001, genetic scientists reported that they had designed a gene that might lead to a future treatment of sickle cell anemia. Although the gene had not been tested in humans, early results showed that the injected gene protected cells from sickling. As of 2003, experiments in gene therapy for sickle cell disease have been carried out in mice, using lentiviral vectors to transfer the corrective gene into the mouse's stem cells. This technique, however, has not yet been attempted in human subjects as of late 2003.

Prognosis

Hemoglobinopathies are life-long disorders. The prognosis depends upon the exact nature of the mutation, the availability of effective treatment, as well as the individual's compliance with therapies. Hemoglobinopathies significantly complicate pregnancy, and increase the risk of infant mortality.

Prevention

Because the hemoglobinopathies are inherited diseases, primary prevention involves carriers making reproductive decisions to prevent passage of the abnormal gene to their offspring. At present, most prevention is targeted toward the symptoms using treatments such as those described above.

KEY TERMS

Amino acids— Organic compounds that form the building blocks of protein. There are 20 different amino acids.

Autosomal recessive— A pattern of inheritance in which both copies of an autosomal gene must be abnormal for a genetic condition or disease to occur. An autosomal gene is a gene that is located on one of the autosomes or non-sex chromosomes. When both parents have one abnormal copy of the same gene, they have a 25% chance with each pregnancy that their offspring will have the disorder.

Hemoglobin— Protein-iron compound in the blood that carries oxygen to the cells and carries carbon dioxide away from the cells.

Hydroxyurea— A drug that has been shown to induce production of fetal hemoglobin. Fetal hemoglobin has a pair of gamma-globin molecules in place of the typical beta-globins of adult hemoglobin. Higher-than-normal levels of fetal hemoglobin can prevent sickling from occurring.

Phlebotomy— Drawing blood from a vein for diagnosis or treatment. Phlebotomy is sometimes used in the treatment of hemoglobinopathies to lower the iron concentration of the blood.

Sickle cell— A red blood cell that has assumed an elongated shape due to the presence of hemoglobin S.

Splenomegaly— Enlargement of the spleen.

Resources

BOOKS

Beers, Mark H., MD, and Robert Berkow, MD., editors. "Anemias Caused by Excessive Hemolysis: Sickle Cell Diseases." Section 11, Chapter 127 In The Merck Manual of Diagnosis and Therapy. Whitehouse Station, NJ: Merck Research Laboratories, 2004.

Beers, Mark H., MD, and Robert Berkow, MD., editors. "Pregnancy Complicated by Disease: Hemoglobinopathies." Section 18, Chapter 251 In The Merck Manual of Diagnosis and Therapy. Whitehouse Station, NJ: Merck Research Laboratories, 2004.

Behrman, Richard E., et al. Nelson Textbook of Pediatrics. 16th ed. Philadelphia, W. B. Saunders, 2000.

Jorde, Lynn B., et al. Medical Genetics. 2nd ed. New York: Mosby, 1999.

PERIODICALS

Davies, S. C., and A. Gilmore. "The Role of Hydroxyurea in the Management of Sickle Cell Disease." Blood Reviews 17 (June 2003): 99-109.

Koduri, P. R. "Iron in Sickle Cell Disease: A Review Why Less Is Better." American Journal of Hematology 73 (May 2003): 59-63.

Krishnamurti, L., S. Abel, M. Maiers, and S. Flesch. "Availability of Unrelated Donors for Hematopoietic Stem Cell Transplantation for Hemoglobinopathies." Bone Marrow Transplantation 31 (April 2003): 547-550.

Markham, M. J., R. Lottenberg, and M. Zumberg. "Role of Phlebotomy in the Management of Hemoglobin SC Disease: Case Report and Review of the Literature." American Journal of Hematology 73 (June 2003): 121-125.

Nienhuis, A. W., H. Hanawa, N. Sawai, et al. "Development of Gene Therapy for Hemoglobin Disorders." Annals of the New York Academy of Science 996 (May 2003): 101-111.

Olivieri, Nancy F. "The Beta-Thalassemias." The New England Journal of Medicine 341, no. 2 (July 1999): 99-109.

Steinberg, M. H., F. Barton, O. Castro, et al. "Effect of Hydroxyurea on Mortality and Morbidity in Adult Sickle Cell Anemia: Risks and Benefits up to 9 Years of Treatment." Journal of the American Medical Association 289 (April 2, 2003): 1645-1651.

ORGANIZATIONS

American Sickle Cell Anemia Association. 〈http://www.ascaa.org〉.

National Marrow Donor Program (NMDP). Suite 500, 3001 Broadway Street Northeast, Minneapolis, MN 55413. (800) 627-7692. 〈http://www.marrowdonor.org〉.

Sickle Cell Disease Association of America, Inc. 200 Corporate Point Suite 495, Culver City, CA 90230-8727. (800) 421-8453. [email protected]. 〈http://sicklecelldisease.org/〉.

Sickle Cell Information Center. PO Box 109, Grady Memorial Hospital, 80 Bulter Street, SE, Atlanta, GA 30303. (404) 616-3572. 〈http://www.emory.edu〉.

Hemoglobinopathies

Hemoglobinopathies are diseases caused by the production of abnormal hemoglobin or by a deficiency of hemoglobin synthesis. Hemoglobin is the protein in red blood cells (erythrocytes) that binds to oxygen, to distribute it throughout the body. The major hemoglobinopathies are sickle cell disease and several forms of thalassemia.

Hemoglobin Structure and Function

In the lungs, where oxygen concentration is high, each hemoglobin molecule can bind with one molecule of oxygen. The erythrocyte containing the hemoglobin then travels through the bloodstream to the body's cells, where oxygen concentration is low, and the hemoglobin releases the oxygen for use by local tissue. It also picks up carbon dioxide, and this waste product is transported back to the lungs, where it can be released and exhaled.

Hemoglobin is made up of heme and globin. Heme is an iron-containing pigment that binds to oxygen. Globin, which holds the heme and influences how easily it stores and releases oxygen, is a protein consisting of two pairs of polypeptide chains. Globin can contain several different types of polypeptide chains, termed alpha, beta, and gamma. Each is coded for by a separate gene. The genes are evolutionarily related, and their differences are the result of ancient mutation events in an ancestral form that gave rise to each modern type.

The type of hemoglobin found in healthy adults contains two alpha chains and two beta chains. This form of hemoglobin is called HbA (hemoglobin A). As discussed below, sickle cell disease is due to mutations in the beta chains in HbA. A fetus or newborn baby does not produce HbA. Instead, it produces fetal hemoglobin, or HbF. Like HbA, fetal hemoglobin contains a pair of alpha chains. But in place of the beta chains, it contains a pair of gamma chains. As infants grow older, their bodies produce less and less HbF and more and more HbA.

The Genetics of Hemoglobinopathies

Each person possesses two copies of the beta globin gene, on separate homologous chromosomes. In most people, the two copies are identical. A person with two identical gene copies is said to be homozygous.

In some people, the two beta copies are not identical. These people, who have two different alleles of the beta globin gene, are said to be heterozygous. The beta globin allele that leads to sickle cell disease is called the hemoglobin S (HbS) allele.

People who have inherited one HbA and one HbS allele are heterozygous for the beta chain gene. They are said to have the sickle cell trait, but not sickle cell disease. As long as they have one HbA allele, these individuals produce sufficient HbA to remain healthy, and they usually do not have any medical problems, or they experience only very mild symptoms. When both alleles must be abnormal to cause a disease, the condition is said to be recessive. Sickle cell disease is a recessive condition.

Sickle cell disease can occur when two individuals who have the sickle cell trait (they are called carriers) have children. Recall that the two beta chain alleles occur on different chromosomes. These homologous chromosomes separate during gamete formation, so that each gamete has a fifty-fifty chance of possessing an HbS allele. There is a one-in-four chance that a child conceived by two carriers will inherit a recessive , abnormal allele from each parent, and therefore be homozygous for the abnormal allele and develop sickle cell disease.

Homozygous forms of hemoglobinopathy can be very serious. Some cause so much damage that the fetus dies before birth, while others require lifelong treatment.

Sickle Cell Disease

Sickle cell disease is the most prevalent genetically based disease in the United States. Approximately 1 in 12 Americans of African descent are carriers, having one allele coding for HbS and one gene for HbA. About 1 in 375 Americans of African descent are homozygous for HbS and have the active disease. High occurrence of the HbS allele also occurs in people who live, or whose ancestors lived, in certain parts of Asia, the Mediterranean, and the Middle East.

The alpha chain gene is found on chromosome 11. Each gene is made up of a very long strand of nucleotides. In sickle cell disease, there is a change in only one nucleotide in the sequence that codes for the beta chain: A thymine is substituted for an adenine.

Genes code for proteins. Because of that change in one nucleotide, a slightly different protein is produced. HbS differs from HbA by only one amino acid: Glutamic acid in HbA is replaced by valine in the sixth position on the beta chain. The substitution does not affect the hemoglobin molecule's ability to bind with oxygen. HbS can carry oxygen just as effectively as HbA. However, glutamic acid is a hydrophilic ("water-loving") amino acid, whereas valine is hydrophobic ("water-hating"). The valine occurs on the outside of the beta chain. The hydrophobic portions of HbS molecules are attracted to each other. When the concentration of oxygen is low, as it is deep in the body's tissues, HbS molecules will attach to each other. Since a single red blood cell contains about 250 million hemoglobin molecules, this can result in very long chains, or polymers .

The polymerization that occurs distorts the red blood cell into a curved, sickle shape. Whereas normal erythrocytes travel smoothly through the blood vessels, these unusually elongated and pointed erythrocytes move much more slowly and can block smaller blood vessels. Both the slow movement and the blockages further reduce the amount of oxygen in the blood, promoting even more polymerization and sickling.

The decreased amount of oxygen in the blood also damages local tissues and will cause permanent damage if it lasts long enough. The lack of oxygen is very painful. This progressive cycle of worsening symptoms, called a vaso-occlusive crisis, can last for more than a week.

People with sickle cell disease often develop other health problems. For example, the crescent shaped erythrocytes have shorter life spans than normally shaped cells do. A healthy red blood cell lives about 120 days, while a sickle cell lives only for 10 to 30 days. The body is unable to replace the red blood cells quickly enough, resulting in anemia.

Situations that cause the body to use up oxygen, such as exercise, can precipitate a vaso-occlusive crisis. Also, because dehydration causes the hemoglobin molecules to be packed more tightly together within the erythrocyte, insufficient fluid intake can also cause red blood cells to sickle.

Treatment Options and Continuing Research

Therapy for sickle cell disease used to focus on easing symptoms and treating infections, which are the most common cause of death in children who have this disease. Newer therapies actually treat the disease.

Hydroxyurea and erythropoietin, for example, are two medications that stimulate the bone marrow to produce more fetal hemoglobin, HbF. Production of both red blood cells and hemoglobin occurs in this spongy tissue, which is located in certain bones.

Fetal hemoglobin can transport oxygen but does not polymerize, so the red blood cells cannot sickle. Thus these drugs can prevent vaso-occlusive crises. However, they do have side effects that can limit their usefulness. Hydroxyurea, for example, can suppress bone marrow function.

Normally, the production of HbF is turned off shortly after birth. Scientists are trying to determine how to reactivate the gene for HbF so that the bone marrow of people with sickle cell disease can continually produce fetal hemoglobin without the use of medications. Other research focuses on learning how to insert normal beta chains and regulatory genes into stem cells , which are cells that develop into erythrocytes.

Bone marrow transplants are a new treatment and have largely been conducted in Europe. The donor bone marrow will produce normal hemoglobin and normal red blood cells. However, the tissue must come from an immunologically compatible donor. Also, a bone marrow transplant is a complicated process, and some people have died during the procedure.

Hemoglobin C Disease

Hemoglobin C (Hbc), which is also found in people of African or Mediterranean descent, is very similar in structure to HbS. Both are caused by a change in the sixth residue of the beta chain. While valine replaces glutamic acid to form HbS, the amino acid lysine is found in this position, in HbC.

The substitution of lysine does not cause pathological changes in the hemoglobin molecule. People who are homozygous for HbC typically have red blood cells that appear unusual, but they do not sickle. These individuals have no symptoms, and they do not require treatment.

Some people have one gene for HbC and another for HbS. They have hemoglobin SC disease, which usually is much less severe than sickle cell disease.

The Thalassemias

The thalassemias are a group of hemoglobinopathies that, like sickle cell disease, are caused by a genetic change. Unlike sickle cell disease, however, the genetic change does not result in the production of an abnormal form of the globin molecule. Instead, the bone marrow synthesizes insufficient amounts of a hemoglobin chain. This, in turn, reduces the production of red blood cells and causes anemia.

Either the alpha or beta chain may be affected, but beta thalassemias are more common. Individuals who are heterozygous for this disorder have one allele for this disease and one normal allele and are said to have thalassemia minor. They usually produce sufficient beta globin so that they have only mild anemia. They may not have any symptoms at all. Thalassemia minor is sometimes misdiagnosed as iron deficiency anemia.

If two individuals with thalassemia minor have children, there is a onein-four chance that each child will inherit an abnormal gene from both parents and will be homozygous for the disorder.

Individuals who are homozygous for this condition may develop either thalassemia intermedia or thalassemia major. Newborn babies are healthy because their bodies are still producing HbF, which does not have beta chains. During the first few months of life, the bone marrow switches to producing HbA, and symptoms start to appear.

In thalassemia major, also called Cooley's anemia, the bone marrow does not synthesize beta globin at all. Children affected by thalassemia major become very anemic and require frequent blood transfusions. They are so ill that they often die by early adulthood.

In thalassemia intermedia, the production of beta globin is decreased, but not completely. People with this disease have anemia, but they do not require chronic blood transfusions to stay alive.

Alpha thalassemia is more complicated, because an individual inherits two alpha globin genes from each parent for a total of four alpha globin genes. Thus a person can inherit anywhere from zero to four normal genes.

The more abnormal alpha genes that are inherited, the greater the symptoms. If an individual does not have any functional alpha genes, the body cannot produce any alpha globin. Since HbF requires alpha chains, the developing fetus does not produce healthy hemoglobin and shows severe symptoms even before birth. This condition is almost always fatal, with affected infants dying either before or shortly after delivery.

The loss of three functional alpha genes produces severe anemia, the loss of two functional genes typically causes mild anemia, and the loss of only one gene usually does not produce any symptoms. The thalassemias most commonly occur in people from Italy, Greece, the Middle East, Africa, and Southeast Asia; and in their descendants.

Treatment Options and Continuing Research

Blood transfusions have been a common therapy for severe thalassemia, but transfusions do not cure the disease, and frequent transfusions can cause iron overload, an illness caused by excessively high levels of iron. A drug, called an iron chelator, may be given to bind with the excess iron. Iron chelators can produce additional side effects, such as hearing loss and reduced growth.

As with sickle cell disease, gene therapy and bone marrow transplants are very promising therapies for severe thalassemias. While transplants are risky procedures and can cause death, they are more likely to be successful when performed on young and relatively healthy children.

The Heterozygous Advantage

Being homozygous for either sickle cell disease or thalassemia can result in serious illness, but being heterozygous for either condition may actually be beneficial under certain circumstances. Both diseases occur primarily in people who live, or whose ancestors lived, in parts of the world where malaria occurs.

Malaria is spread by a mosquito, but it is caused by plasmodia, single-celled organisms that, during an infection, reproduce inside red blood cells. Before the development of modern sanitation and medicine, malaria was a common cause of death. But people who had either the sickle cell trait or thalassemia minor—people who were heterozygous for either condition—were much more likely to survive an infection than were people homozygous for HbA.

This "heterozygote advantage" meant that these individuals tended to live longer, have children and pass their genes on to the next generation. While some of their children died from thalassemia or sickle cell disease, about half of them were heterozygous and benefited from the heterozygote advantage. This survival advantage explains the high prevalence of these alleles in these populations.

Today, especially in developed countries, there are effective methods for preventing and treating malaria. Nevertheless, the genes for sickle cell disease and thalassemia still exist and are passed down to children who will never be exposed to malaria. It is likely that these genes will very slowly be lost from the gene pool.

see also Genotype and Phenotype; Heterozygote Advantage; Inheritance Patterns; Mutation; Population Screening; Proteins; Transplantation.

Sue Wallace

Bibliography

Weatherall, D. J. "ABC of Clinical Haematology: The Hereditary Anaemias." British Medical Journal 314 (1997): 492-496.

Internet Resources

"Bioelectronics Laboratory Index." Seikei University. <http://www.ee.seikei.ac.jp/user/seiichi/lecture/Biomedical/02/graphics/hemoglobin.gif>.

Facts about Sickle Cell Disease. National Heart, Lung, and Blood Institute. <http://www.nhlbi.nih.gov/health/public/blood/sickle/sca_fact.txt>.

Joint Center for Sickle Cell and Thalassemic Disorders. <http://sickle.bwh.harvard.edu>.

HEMOGLOBINOPATHIES

The term "hemoglobinopathy" has been used to describe abnormalities of hemoglobin, such as sickle-cell disease. Most common are those of hereditary origin in which there is a substitution of one or more of the amino acids in the amino acid chains that form either the [.alpha]- or the ß-globin (alpha- and beta-globin) chains. Some of these genetic changes, such as the substitution of valine for glutamic acid that causes sickle-cell hemoglobin, are common in certain ethnic groups. Others are quite rare. Some hemoglobinopathies, such as those that produce sickle-cell disease and those that produce unstable hemoglobin, cause anemia. Other hemoglobinopathies result in a hemoglobin that does not carry oxygen efficiently, giving a brownish cast to the blood. Thalassemias such as "Mediterranean anemia" are sometimes classified as hemoglobinopathies, but differ in that they are characterized by quantitative deficiencies in hemoglobin chains, not abnormal chains.

Ernest Beutler

(see also: Hemoglobin )